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A 10-year-old girl with no significant medical history presented with an inflammatory mass on the upper back. It had started 3 months earlier, with upper back pain, asthenia, anorexia, weight loss (2 kg), low-grade evening fever and night sweats.
Physical examination revealed painless inflammatory cellulitis of the upper back, with a large central cutaneous fistula discharging pus, and a stiff neck. A pyramidal syndrome was found, with no motor deficiency. The upper lobes showed dullness; she had no respiratory complaints and several decayed teeth.
Laboratory tests showed a high white blood cell count (23 300/mm3), microcytic anaemia (Hb 7.5 g/dl), thrombocytosis (935 000/mm3), C-reactive protein at 132 mg/l and a 1 h erythrocyte sedimentation rate of 126 mm. Chest x-rays showed irregular opacities of the upper lobes and an enlarged upper mediastinum. Computed tomography showed high apical density, crossing the pleura through the upper mediastinum and vertebral spine. Magnetic resonance imaging showed an anterior and posterior epidural abscess, spondylitis from the third to the fifth dorsal vertebra, and posterior cellulitis with fistula.
Tests for aerobic and anaerobic bacteria were negative. Surgical biopsy of the fistula showed a chronic inflammatory process including central suppurative necrosis surrounded by granulation tissue and intense fibrosis. Testing for mycobacteria was negative. Gram staining revealed Gram-positive branching filaments within so-called sulphur granules, typical of actinomyces.
Treatment consisted of penicillin G for 12 months with a cervicothoracic brace for 6 months. The patient fully recovered, with no relapse after 18 months of follow-up.
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication.